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INT’L. J. AGING AND HUMAN DEVELOPMENT, Vol. 72(2) 83-110, 2011

FACTOR STRUCTURE AND PSYCHOMETRIC PROPERTIES OF THE CENTER FOR EPIDEMIOLOGIC STUDIES DEPRESSION SCALE (CES-D) IN OLDER POPULATIONS WITH AND WITHOUT COGNITIVE IMPAIRMENT

L. ROS

J. P. SERRANO

J. M. LATORRE

B. NAVARRO

M. J. AGUILAR

J. J. RICARTE

University of Castilla La Mancha, Spain

ABSTRACT

The CES-D is widely used for the assessment of depressive symptoms in the adult population. However, few studies have been performed to assess the utility of this scale in an older population with cognitive impairment. The factor structure of the Spanish version of the CES-D was examined in an observational, cross sectional study in 623 older adults (M = 72.74 years; SD = 7.7). The validity of the scale was determined in two samples of older adults, one comprising 162 participants with cognitive impairment (M = 76.73 years; SD = 8.1) and one with 58 participants without cognitive impairment (M = 74.64 years; SD = 9.0). The results confirm previous results of a four factor structure. With regard to the validity of the scale, in the group with cognitive impairment the area under the ROC curve is 0.84 (95% CI: 0.77-0.89) and the cut-off point for possible depression is 13, while in the group without cognitive impairment the area is 0.90 (95% CI: 0.79-0.96) and the optimal cut-off point is 28. These results show that the Spanish version of the CES-D is a valid instrument for the identification of depression in older adults with and without cognitive impairment. 83 Ó 2011, Baywood Publishing Co., Inc. doi: 10.2190/AG.72.2.a http://baywood.com

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The Center for Epidemiological Studies-Depression Scale (CES-D; Radloff, 1977) is one of the most widely used self-report scales for depressive symptoms. This scale was originally designed for use with the general adult population and, although originally Radloff designed it to be used for scientific ends and not for clinical purposes, it is currently one of the most commonly used screening instruments in primary care practice (Schulberg, Saul, McClelland, Ganguli, Christy, & Frank, 1985; Williams, Pignone, Ramirez, & Perez, 2002). The aim of this scale is to measure the subject’s mood state based on the frequency he or she experienced certain depressive symptoms in the past week. Furthermore, it may be used to assess changes in a person’s mood state over time. The scale is made up of 20 items that cover areas such as depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, loss of energy, sleep disturbance and loss of appetite. Radloff (1977) selected these items from a sample of several previously validated depression scales such as the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), Zung’s Self-rating Depression Scale (Zung, 1965), or the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943). The responses to each of the 20 items are scored on a 4-point Likert-type scale ranging from “rarely or none of the time” (0) to “most or all of the time” (3). Four of the items are formulated to have a positive slant to evaluate positive mood and to break tendencies toward a response set. The total score ranges from 0 to 60 with the higher scores indicating more symptoms of depression. A score of 16 or more has been widely used as the cut-off point for clinically significant depressive symptomatology (Radloff & Teri, 1986). With regard to reliability, Radloff (1977) found that the mean correlation between test-retest scores after 2, 4, 6, and 8 weeks was 0.57; and the test-retest correlations after 3, 6, and 12 months ranged from 0.32 to 0.54. Subsequently, several studies have corroborated the opinion that the CES-D is a highly reliable measurement instrument (Orme, Reis, & Herz, 1986; Roberts, Andrews, Lewinsohn, & Hops, 1990). The first validation studies confirmed that the CES-D correlates well with clinical ratings of depression (Roberts & Vernon, 1983; Weissman, 1987). Since these initial studies, the CES-D has been widely used as a screening tool in different populations such as clinical patients, adolescents, older adults, workers, etc. (e.g. Bay, Hagerty, Williams, Kirsch, & Gillespie, 2002; Chwastiak, Ehde, Gibbons, Sullivan, Bowen, & Kraft, 2002; Furukawa, Hirai, Kitamura, & Takahashi, 1997; Grant, Gil, Floyd, & Abrams, 2000; Iwata, Okuyama, Kawakami, & Saito, 1989; Lee, Stewart, Byrne, Wong, Ho, Lee, et al., 2008; Liang, Tran, Krause, & Markides, 1989; McArdle, Johnson, Hishinuma, Miyamoto, & Andrade, 2001; Orme et al., 1986; Paterniti, Niedhammer, Lang, & Consoli, 2002; Radloff, 1991; Vedhara, Schifitto, & McDermott, 1999; Verdier-Taillefer, Gourlet, Fuhrer, & Alperovitch, 2001; Yang, Soong, Kuo, Chang, & Chen, 2004).

STRUCTURE AND PSYCHOMETRY OF CES-D /

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According to Radloff and Teri (1986), the CES-D is highly reliable, has a stable factor structure and age, and demographic variables and physical health do not significantly affect scores and factors. In this respect, a subsequent study by Lewinsohn, Seeley, Roberts, and Allen (1997) concluded that the utility of the CES-D was not degraded by age, physical disease, cognitive, or functional impairment. O’Rourke (2004) also found that CES-D responses do not vary depending on the subject’s sex. Factorial Structure of the CES-D Radloff (1977) was the first to investigate and identify the factorial structure of the CES-D through principal component analysis with a varimax rotation. In her study she found four principal factors that accounted for 48% of the variance: depressed mood (7 items, e.g., “I thought my life had been a failure”); positive mood (4 reverse-coded items; e.g., “I felt hopeful about the future”); somatic symptoms and psychomotor retardation (7 items, e.g., “I did not feel like eating; my appetite was poor”); and interpersonal difficulties (2 items, e.g., “I felt that people dislike me”). The original validation study included an adult population who were predominantly White and with a certain level of education. The depressed mood factor accounted for the highest percentage of variation (16%) and interpersonal factor accounted for the lowest percentage of variance (8%). Furthermore, Radloff also generated standard data for subgroups of age (less than 25, 25-64, and over 64 years) for men and women, for African-Americans and White Americans and for different education levels (primary, secondary, higher). The exploratory factor analyses indicated that the factorial structure did not differ among these subgroups, or from the standard generated for the whole of the sample population. Since this initial study, the factorial structure of the CES-D has been examined using many different population samples including age, ethnic group, language, and geographical characteristics in the general population, as well as patients with different diseases. Many of these studies have confirmed the validity of the four factors found by Radloff (1977), although there are some others that have found different factor structures (see Table 1). Nevertheless, despite the diversity of results, a systematic review recently performed by Shafer (2006) found that the four factor structure originally described by Radloff (1977) is the most common structure and that it is robust across different patient groups. Finally, a higher order factor has not always been examined using confirmatory factor analysis methodology. However, in general, where it has been examined a higher order factor has emerged (e.g., Hertzog, Van Alstine, Usala, Hultsch, & Dixon, 1990; O’Rourke, 2003; Sheehan, Fifield, Reisine, & Tennen, 1995).

Sample 253 patients with TBI (71.1% males)

1000 urban adults (41.2% males)

227 older African Americans (25% males) 193 hepatitis C virus-infected injection drug users (75.6% males) 5191 Latino-American adults (42.5% males) 707 adults

414 Black adults and 292 White adults (28% males)

Study

Bush, Novack, Schneider, & Madan (2004)

Clark, Aneshensel, Frerichs, & Morgan (1981)

Foley, Reed, Mutran, & DeVellis (2002)

Golub, Latke, Hagan, Havens, Hudson, Kapadia, et al. (2004)

Guarnaccia, Angel, & Worobey (1989)

Hertzog, Van Alstine, Usala, Hultsch, & Dixon (1990)

Jones-Webb & Snowden (1993)

Confirmed the four-factor structure proposed by Radloff (1977).


Three-factor structure: 1) affect/somatic; 2) interpersonal; and 3) positive affect .36.

Two factor structure: 1) negative affect/depressed affect/somatic; and 2) positive affect.



Four-factor structure: 1) some dysphoric affect and somatic/reduced activity items; 2) some dysphoric affect and interpersonal items; 3) positive affect items; and 4) some somatic/reduced activity items.

Factor structure

Table 1. Studies Examining the Factorial Structure of the CES-D

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340 patients with TBI (70.9% males)

2866 older Mexican Americans

426 low socioeconomic status African Americans 1403 urban Latino participants (62% males)

562 psychiatric patients

179 low income women

470 patients with systemic sclerosis (86% females) 400 adults (49.8% males)

McCauley, Pedroza, Brown, Boake, Levin, Goodman, et al. (2006)

Miller, Markides, & Black (1997)

Nguyen, Kitner-Triolo, Evans, & Zonderman (2004)

Posner, Stewart, Marin, & Perez-Stable (2001)

Roberts, Vernon, & Rhoades (1989)

Thomas & Brantley (2004)

Thombs, Hudson, Schieir, Taillefer, & Baron (2008)

Thorson & Powell (1993)

Five-factor model: 1) depressed affect; 2) somatic; 3) interpersonal; 4) positive affect; and 5) self-worth.


Three-factor structure: 1) depressed affect/somatic symptoms; 2) positive affect; and 3) interpersonal difficulties


Four-factor model proposed by Radloff (1977) provide adequate fit to the data for Latina women but not fit the data for Latino men.


Two factor structure: 1) negative affect; and 2) positive affect


STRUCTURE AND PSYCHOMETRY OF CES-D / 87

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Use of the CES-D in Older Adults The CES-D has also been widely used in older adults. It has been determined that older adults have no difficulty in understanding and following the CES-D instructions and that its sensitivity and specificity in older adults are comparable to those in younger adults (Radloff & Teri, 1986). In this respect, a systematic review by Watson and Pignone (2003) reveals that the CES-D is a useful, valid screening tool for the detection of non-diagnosed depression in older adults in a primary care setting. The findings of various studies are along the same lines (Spijker, van der Wurff, Poort, Smits, Verhoeff, & Beekman, 2004, with elderly migrants from Turkey and Morocco; Foley, Reed, Mutran, & DeVellis, 2002, with older African-Americans). In general, the internal consistency of the CES-D is considered acceptable for both community and clinical samples (e.g., Cronbach’s a = 0.85 to 0.91; Himmelfarb & Murrell, 1983). In view of this, although the CES-D was originally developed and validated for a general adult population, it appears to be appropriate for use in older adult populations. These good indices also apply to the different adaptations of this scale. For example, Reyes-Ortega et al. (2003) developed a Hispanic version of the CES-D in Mexico for use in older adults. They administered the scale to 288 persons aged over 60 years. A noteworthy result is the scale’s high internal consistency (Cronbach’s a = 0.90), with no differences between gender and age groups. In a CES-D validation study among older adults in Brazil, Batistoni, Neri, and Cupertino (2007) also found good internal validity (Cronbach’s a = 0.86). The results indicated acceptable sensitivity and specificity (74.6% and 73.6%, respectively) with a cut-off point of > 11, but with the drawback of having a high rate of false negatives. Beekman et al. (1997) studied the criterion validity of the CES-D in a sample of older adults in the Netherlands using a cut-off point of 16 or over and found very satisfactory sensitivity and specificity (100% and 88%, respectively). However, these authors also found that in patients with physical diseases, cognitive impairment, or anxiety, this cut-off point results in high false positive rates. In view of this and given the prevalence of chronic diseases in this type of population, several studies have determined that, depending on the context, cut-off points of between 20 and 27 could be recommended (Himmelfarb & Murrell, 1983; Schulberg et al., 1985; Zich, Atkinson, & Greenfield, 1990). For example, Harringsma, Engels, Beekman, and Spinhoven (2004) evaluated the validity of the CES-D within the framework of a depression prevention program in Holland. These authors concluded that the scale’s criterion validity was satisfactory as a screening tool, setting a score of 25 as the cut-off point for the diagnosis of clinical depression in persons with psychopathological comorbidity and a history of depressive episodes. With respect to the CES-D factorial structure in older adults, we found that the original four-factor structure proposed by Radloff (1977) is repeatedly used. In the study by Hertzog et al. (1990), the responses of the older adults to the


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CES-D items reflect a complex four-factor structure, each of which significantly contributes to a higher order depression construct. Several studies have replicated this factorial structure in different types of geriatric populations (Foley et al., 2002; Jones-Webb & Snowden, 1993; O’Rourke, 2003). However, the exploratory factor analysis performed in the study by Batistoni et al. (2007) revealed only three factors: negative affect, problem initiating behavior, and positive affect. Spanish Version of the CES-D In 2001, Mui, Burnett, and Chen published a review in which they analyzed the utility and psychometric properties of the CES-D. They confirmed its value as a diagnostic tool for depression in older persons of diverse cultures. Some authors have suggested that there is a need for validating a CES-D for each cultural group (Gupta & Yick, 2001; Mui, Burnett, & Chen, 2001; Riddle, Blais, & Hess, 2002). Latorre and Montañés (1997) used their first Spanish version of the CES-D in a sample of 230 adults aged over 60 years in Spain. They used the cut-off point of 16 originally proposed by Radloff (1977). Using exploratory factorial analysis they identified four factors in their version, which coincided with the factorial structure proposed by Radloff (1977). They found that these four factors accounted for 60.8% of the scale’s variance. Subsequently, the study by Zunzunegui et al. (1998) also attempted to validate the CES-D scale in older adults in Spain. These authors used the version of the scale developed for the HHANES, a study on depressive symptoms in a Mexican American population (Moscicki, Locke, Rae, & Boyd, 1989). Zunzunegui et al. studied a sample of 98 adults aged over 65 years (4 of whom had major depression and 13 had dysthymia). Their results revealed that the CES-D had good internal consistency (Cronbach’s a = 0.89) and, with a cut-off point of 16 or over, the scale had 100% sensitivity and 73% specificity for the diagnosis of major depression. This study has two main objectives. First, we aim to determine the internal consistency and reliability of the CES-D in a sample of older adults much larger than that of Latorre and Montañés (1997) and of Zunzunegui et al. (1998). We will also examine the factorial structure of the scale in this type of sample using structural equation models. Secondly, we will assess the diagnostic validity of the CES-D in two different populations of Spanish older adults. The first is a group of older adults without cognitive impairment. As in previous studies (Himmelfarb & Murrell, 1983; Schulberg et al., 1985; Zich et al., 1990), we expect the recommended cut-off point to be higher than the conventionally used one of 16. The second sample is a group of older adults with mild cognitive impairment. As we have already seen, the CES-D is recommended for assessing depressive symptoms in old age (Himmelfarb & Murrell, 1983; Lewinsohn et al., 1997; Radloff & Teri, 1986); however, it has been rarely examined in older persons with cognitive impairment.

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To our knowledge, the only study in this respect is that of Lewinsohn et al. (1997). These authors found that in a sample of older adults with cognitive impairment a cut-off point of 12 maximized the scale’s sensitivity and specificity, clearly lower than the score of 20 suggested by other investigators for an older population (Himmelfarb & Murrell, 1983; Lyness, Noel, Cox, King, Conwell, & Caine, 1997). In view of this, we aim to evaluate the diagnostic validity of the CES-D in a sample of older adults with mild cognitive impairment and to determine the most appropriate cut-off point for this type of population. METHOD Participants The voluntary participants were recruited from six community centers for older adults in Albacete, Spain (two cultural centers, one social service center, two centers for retired people, and the geriatric department of a hospital in Albacete). A total of 623 persons aged over 65 years participated in the study. The mean age was 72.74 (SD = 7.7), 60% were women and 42.2% had mild cognitive impairment. As regards educational level, 35.3% of the participants could read and write at some level but did not attend any school, 46.1% had completed primary education attending a school (6 years of schooling), 9.3% secondary education, and 9.3% higher education. The entire sample was assessed by the five clinical psychologists participating in the study. For the determination of the diagnostic validity of the CES-D in older adults with and without cognitive impairment, all the participants came from the geriatric department of a hospital in Albacete (CHUAB). These participants had been diagnosed using the Composite International Diagnostic Interview (WHO-CIDI, 2001). The Mini Examen Cognitivo (MEC; Lobo, Ezquerra, Gómez-Burgada, Sala, & Seva-Diaz, 1979) was used to assess the level of cognitive impairment. The sample of older adults without cognitive impairment consisted of 58 persons aged over 65 years (22 had major depression disorder (MDD) and 36 did not). The mean age of the non-depressed group was 73.31 (SD = 8.0) and 38.9% were women. As regards educational level, 36.1% of the subjects could read and write without attending any school, 47.2% had completed primary education, 5.6% had completed secondary education, and 11.1% had completed higher education. The mean age of the MDD group was 76.82 (SD = 9.8) and 86.4% were women. Lastly, the educational level of this group was as follows: 63.7% could read and write without attending any school and 36.4% had completed primary education. The sample of older adults with mild or incipient cognitive impairment comprised 162 persons aged over 65 years (82 participants with MDD and 80 without MDD). The mean age in the non-depressed group was 77.01 (SD = 7.9) and 53.8% were women. As regards educational level, 48.7% of the subjects could


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read and write without attending any school, 41.3% had completed primary education, and 10% had completed secondary education. The mean age of the MDD group was 76.45 (SD = 8.2) and 69.5% were women. Lastly, the educational level of this group was as follows: 58.5% could read and write without attending any school and 40.3% had completed primary education and 1.2% had completed secondary education. Instruments Center for Epidemiological StudiesDepression Scale (CES-D; Radloff, 1977)

The Spanish version of the CES-D developed by Latorre and Montañés (1997) was used in this study. Two forward and two back translations of the original CES-D were performed to develop the Spanish CES-D, stressing conceptual and linguistic equivalence. Two bilingual primary care doctors were asked to translate the CES-D from English into Spanish. Then, two different doctors translated it back into English and a public translator compared the original version against the translated ones. All translators were blind to the translation of the others. Small semantic differences were discussed and agreed upon to obtain the final version (see Appendix 1). Mini Examen Cognitivo (MEC; Lobo et al., 1979)

The MEC is a screening instrument widely used for the detection of cognitive impairment. It is made up of 35 items that assess the following cognitive functions: time and space orientation, attention, mental arithmetic, immediate verbal recall, short-term deferred verbal recall, verbal working memory, abstract verbal reasoning, language, and visoconstructive praxis. It takes about 10–15 minutes and it is routinely used in both clinical practice and in research studies. The MEC is based on the Mini Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) and has been adapted and validated in Spain by Lobo et al. (1979), with some differences with respect to the original. In both clinical samples and the general population, the MEC has demonstrated satisfactory validity, reliability, and discriminative power with an 82% specificity and an 84.6% sensitivity increasing to 92.3% and 95.2%, respectively, in geriatric patients. In a revalidation and standardization study in a population of adults over 65 years, it was found that if a cut off score of 23–24 points is used, the MEC has a sensitivity of 89% and a specificity of 83.9% (Lobo, Saz, Marcos, Dia, De La, Ventura, et al., 1999). In a population under 65 years, a cut off point of 27 or more is established for the diagnosis of cognitive impairment (Lobo et al., 1979).

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Composite International Diagnostic Interview (CIDI; WHO-CIDI, 2001)

The CIDI is a series of structured interviews designed to assess different mental disorders and addictions according to the diagnostic criteria of DSM-IV and the ICD-10. It allows the investigator to assign a clinical diagnosis. All the questions in each of the interviews follow a simple Yes/No response format. The subject’s responses do not need to be weighed up by the interviewer and this provides for high test-retest reliability and good internal reliability (Cottler, Robins, Grant, Blaine, Towle, Wittchen, et al., 1991; Wittchen, 1994; Wittchen, Robins, Cottler, Sartorius, Burke, Regier, et al., 1991). For our study we used the structured interview for Major Depression, evaluating nine symptoms: 1. 2. 3. 4. 5. 6. 7. 8. 9.

depressed mood state; loss of interest; energy loss/increase; appetite/weight loss/gain (more or less than 2.5 kg); sleep problems; psychomotor problems/listless-agitated; guilt feelings or lack of self-esteem; concentration difficulties; and thoughts about death.

The subjects answered No (1) or Yes (2) to each of the questions. Some symptoms only have one question and others two or more questions. An affirmative response to just one of the questions on a symptom is taken to mean that such symptom is present. If five or more of the nine symptoms are present, then the subject has Major Depressive Disorder (MDD). Procedure Patients from all sites provided informed consent, and the research ethics board of each study site approved the data collection protocol. Before starting a session, participants gave consent, received an explanation of the study, provided basic demographic data, and completed the MEC and CES-D scales. The interviews were individually administered on a session by five psychologists blind to the purpose of the study. Participants were told that the study was investigating the mood state and that the interviews were designed to recruit emotions and feelings related with the mood. RESULTS The frequency distributions of the CES-D scale items indicated that the entire range of response options were employed for each item with only six items (item 1,


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item 2, item 9, item 10, item 15, and item 19) displaying values beyond 1.00 for kurtosis and skewness. Table 2 contains the descriptive statistics for the items comprising the CES-D scales. Reliability of the CES-D The mean CES-D score for the entire sample (n = 623) was 15.17 (SD = 10.64), with a score range of 0-50 (from a maximum score of 60) and 40.8% of the sample scored 16 or more, which is the score commonly used as the cut-off point for possible depression at a first screening stage. The Cronbach’s alpha is acceptable (0.88) and, in general, all the items have a good item-total correlation.

Table 2. Means and Standard Deviations of Items Composing the CES-D Scale (n = 623) Item

Mean

SD

Kurtosis

Skewness

CES-D 1

0.59

0.86

1.06

1.40

CES-D 2

0.50

0.90

1.91

1.76

CES-D 3

0.93

1.07

–0.78

0.76

CES-D 4

0.91

1.08

–0.69

0.83

CES-D 5

0.77

0.96

–0.13

1.01

CES-D 6

0.83

1.03

–0.34

0.97

CES-D 7

0.88

1.04

–0.55

0.85

CES-D 8

1.30

1.15

–1.37

0.27

CES-D 9

0.47

0.88

2.26

1.84

CES-D 10

0.34

0.72

4.65

2.27

CES-D 11

0.84

1.07

–0.63

0.89

CES-D 12

1.06

1.01

–0.85

0.54

CES-D 13

0.64

0.96

0.38

1.29

CES-D 14

0.73

1.05

–0.02

1.18

CES-D 15

0.45

0.73

2.14

1.62

CES-D 16

1.26

1.07

–1.16

0.32

CES-D 17

0.72

1.01

0.09

1.18

CES-D 18

0.88

1.02

–0.49

0.86

CES-D 19

0.36

0.73

4.53

2.22

CES-D 20

0.77

1.01

–0.09

1.08

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Table 3 gives the descriptive analysis of each of the CES-D items. From this table, it may be seen that the responses are skewed toward fewer depressive symptoms. Confirmatory Factor Analysis Confirmatory factor analysis of the CES-D was performed using unweighted least squares (ULS) estimation for the total sample (n = 623). This method was used because the scores obtained for the different CES-D items did not follow a normal distribution (according to the Kolmogorov-Smirnov tests). This made it impossible to use the maximum likelihood estimation (MLE) procedure as its supposition of normal distribution of the variables is violated. Each item was allowed to load on only one factor and the latent variables were allowed to correlate. No residuals from the items were assumed to be correlated. The goodness of fit of the model was evaluated using the following fit indices: goodness of fit index (GFI); root mean-square residual (RMR); normed fit index (NFI); and relative fit index (RFI). Following the recommendations of Blunch (2008), the cut-off values for these fit indices are as follows: for the RMR values below 0.05 are considered a good fit, for the NFI and RFI values above 0.95 are indicative of a good fit, and GFI has been proposed to be analogous to R2 in multiple regression. The confirmatory factor analysis confirmed the original model proposed by Radloff (1977). This model is made up of four latent variables: depressed affect (DA); somatic/reduced activity (SRA); interpersonal relationships (IR); and positive affect (PA; Model 1). Subsequently, a second-order factor version of this initial four-factor model was performed (Model 2). Model 2 is given in Figure 1, together with the standardized estimated parameters. The fit indexes for both models are given in Table 4. It is of note that in both cases, the indices have an excellent fit. Lastly, Table 5 reports the correlations between each of the four factors and the second-order factor loadings for confirmatory factor analysis models. The inter-correlations among the four factors in Model 1 range from 0.33 to 0.86 and the correlations that include the interpersonal relations factor are the lower ones. In Model 2, the higher order factor, Depression, accounts for 99% of the variance of the depressed affect factor, 74% of the variance of the somatic/retarded activity factor, 49% of the variance of the positive affect factor, and only 23% of the variance of the interpersonal relationships factor. Screening Characteristics of the CES-D in Elderly With and Without Cognitive Impairment To evaluate the sensitivity and specificity of the CES-D at various cut-off points, we used ROC analysis. In order to construct a ROC curve, sensitivity and specificity were calculated for several scores of the CES-D. The sensitivity,

0.44 0.31 0.39 0.50 0.37 0.52 0.61 0.30 0.37 0.33 0.34 0.58 0.52

Somatic/Reduced activity CES-D 1 CES-D 2 CES-D 5 CES-D 7 CES-D 11 CES-D 13 CES-D 20

Interpersonal relationships CES-D 15 CES-D 19

Positive affect CES-D 4* CES-D 8* CES-D 12* CES-D 16* 14.0 22.1 11.3 17.5

66.6 74.7

61.0 71.2 52.5 48.6 54.6 63.1 54.8

47.7 51.2 72.2 76.8 60.4 59.0 47.9

12.7 19.4 20.2 21.6

24.0 17.8

24.6 15.1 25.8 25.8 18.3 17.5 23.8

23.8 25.6 15.1 15.3 18.4 20.4 27.1

24.0 25.0 31.6 30.5

7.2 3.8

9.2 6.5 13.9 14.2 15.6 12.1 11.0

15.7 11.9 6.2 4.6 9.2 10.4 14.3

49.3 33.5 36.9 30.4

2.2 3.7

5.2 7.2 7.8 11.4 11.5 7.3 10.4

12.7 11.1 6.5 3.3 12.0 10.2 10.7

0.88 0.88 0.87 0.87

0.88 0.88

0.87 0.88 0.87 0.87 0.88 0.87 0.87

0.87 0.86 0.87 0.87 0.87 0.87 0.86

*For presentation purposes in this table, these items were not reverse-scored so that higher scores indicate higher positive affect (i.e., “Rarely or none of the time” = 0 and “Most or all of the time” = 3).

0.61 0.73 0.44 0.40 0.50 0.60 0.72

Depressed affect CES-D 3 CES-D 6 CES-D 9 CES-D 10 CES-D 14 CES-D 17 CES-D 18

Table 3. Frequrency Distributions, Corrected Item-Total Correlations and Cronbach’s a for the CES-D Items (n = 623) Item-total Rarely/none Some/little Occasionally/ Most/all Item correlation (%) (%) moderate (%) (%) Cronbach’s a


Figure 1. Correlated four-factor second-order model.

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Table 4. Fit Indices for Confirmatory Factor Analysis Models Model Fit Indices

GFI

RMR

NFI

RFI

Model 1: four-factor

0.99

0.04

0.98

0.98

Model 2: four-factor, second-order

0.99

0.04

0.98

0.97

Note: GFI = Goodness of Fit Index; RMR = Root Mean-Square Residual; NFI = Normed Fit Index; RFI = Relative Fit Index.

Table 5. Factor Correlations (Model 1) and Second-Order Factor Loadings (Model 2) for Confirmatory Factor Analysis Models Correlations and second-order factor loadings

DA

SRA

PA

IR

Model 1: correlated four-factor DA S/V PA IP

— 0.86 0.70 0.44

— 0.60 0.47

— 0.33

—

Model 2: second-order factor loadings

0.99

0.86

0.70

0.48

Note: DA = depressed affect; SRA = somatic/reduced activity; PA = positive affect; IR = interpersonal relationship. Italic = standard regression coefficients.

specificity, positive predictive value (PPV), and negative predictive value (NPV) are shown in Table 6. The results for the sample without cognitive impairment suggest a score of 28 as the optimum cut-off point, as this is the cut-off point that optimizes the sensitivity and specificity of the samples studied (81.82% and 94.44%, respectively). In contrast, a cut-off point of 13 is recommended for the sample with cognitive impairment, with a sensitivity of 86.25% and a specificity of 72.37%. Figures 2 and 3 shows the ROC curve for the CES-D in the samples without cognitive impairment and with cognitive impairment, respectively. In the sample without cognitive impairment, the AUC calculated with ROC analysis was 0.90 (95% CI: 0.79-0.96; p < 0.001). In the sample with cognitive impairment, the AUC was 0.84 (95% CI: 0.77-0.89; p < 0.001). As can be seen, both curves are substantially above the random ROC (AUC = 0.5), which represents the sensitivity and specificity or random guesses as to whether an individual is a case or not. The

86.36 86.36 86.36 81.82 81.82 81.82 81.82 81.82 77.27 68.18

13

16

17

19

20

22

27

28

29

30

23.75

26.25

27.50

28.75

51.25

52.50

53.75

62.50

67.50

86.25

S.C.I.

97.22

94.44

94.44

88.89

77.78

75.00

72.22

72.22

71.33

69.44

N.S.

94.74

94.74

93.42

93.42

89.47

88.16

88.16

86.84

85.53

72.37

S.C.I.

Spec (%)

93.75

89.47

90.00

81.82

69.23

66.67

64.29

65.52

64.71

63.33

N.S.

PPV (%)

82.61

84.00

81.48

82.14

83.67

82.35

82.69

83.33

83.08

76.67

S.C.I.

83.33

87.18

89.47

88.89

87.50

87.10

86.67

89.66

89.40

89.29

N.S.

NPV (%)

54.14

54.96

55.04

55.47

63.55

63.81

64.42

68.75

71.43

83.33

S.C.I

Note: PPV = positive predictive value; NPV = negative predictive value; N.S. = normal sample (without cognitive impairment); S.C.I. = sample with cognitive impairment. The prevalence of Major Depressive Disorder was 37.93% in N.S. and 51% in S.C.I.

N.S.

Cut-off score

Sens (%

Table 6. Diagnostic Performance of the CES-D at Different Cut-Off Scores for MDD

98 / ROS ET AL.

Figure 2. Receiver operating characteristics of the CES-D for MMD in sample without cognitive impairment.


/

Figure 3. Receiver operating characteristics of the CES-D for MMD in sample with cognitive impairment.

100 ROS ET AL.


101

fact that the AUC is significantly greater than 0.5 means that the null hypothesis (i.e., that the CES-D provides no useful information) can be rejected. DISCUSSION The two main objectives of this study were: 1. to determine the validity and reliability of the CES-D in a population of older adults and to examine the factorial structure through confirmatory factor analysis with structural equations; and 2. to assess the adequacy of the CES-D as a screening instrument in a population of older adults with and without cognitive impairment. In general, we believe that the results support the use of the CES-D as a valid screening instrument for depression in an older adult population. Nunnally and Bernstein (1994) proposed that for self-report scales to be used as screening instruments, they must have an internal consistency of ³ 0.80. The reliability indices obtained in our study meet this criterion. Furthermore, the fact that the items have high internal consistency confirms the unidimensional nature of the scale. Regarding the factorial structure of the CES-D, our results, using a structural equation model, support the original four factor structure proposed by Radloff (1977): depressed affect; somatic symptoms/psychomotor retardation; positive affect; and interpersonal relationships. Furthermore, in agreement with the findings of studies such as those performed by Hertzog et al. (1990) and Sheehan et al. (1995), our results also lend support to a higher order factor structure of the CES-D in older adults. It should be pointed out that all the items in both models adequately saturate on their respective factors, and all first-order factors significantly saturate on a latent second-order Depression construct. This good fit of the second-order model supports the use of a total CES-D score as an overall indicator of depressive symptomatology in older adults. Therefore, although the interpersonal relationships factor appears to be weakly related with the higherorder Depression construct, total score may be considered as a valid measurement of depressive symptomatology. The results of our second objective—assessing the utility of the CES-D in a sample of older adults with mild cognitive impairment and a sample without cognitive impairment—suggest that CES-D is an acceptable instrument to accurately detect MDD in both samples. The criteria validity of the CES-D was examined by comparing the scale’s cut-off points with those of a gold standard, the CIDI. As we have seen, the CIDI is a structured interview which allows the investigator to clinically diagnose MDD. Through ROC analysis, we found that CES-D is sensitive, specific, and has good positive and negative predictive values, taking the total score of 28 as the cut-off point for the sample without cognitive impairment and 13 for the sample with cognitive impairment. Both these

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cut-off points concur with those in the literature. The cut-off point of 28, in an older population without cognitive impairment, is similar to that suggested as optimum by authors such as Himmelfarb and Murrell (1983) or Schulberg et al. (1985) in an older population. In the older population with cognitive impairment, our cut-off point is similar to that found by Lewinsohn et al. (1997), also in a study in older adults with mild cognitive impairment. It is our opinion that older adults without cognitive impairment and with a CES-D score of over 28, or older adults with cognitive impairment and with a score of over 13, should be assessed in a clinical interview in order to reach a specific clinical diagnosis and administer the appropriate treatment. It should be remembered that the CES-D is not, strictly speaking, a diagnostic instrument; however, it has demonstrated to be very useful as an indicator of probable depression, which should be subsequently evaluated by clinical criteria (Gatz, Kasl-Godley, & Karel, 1996; Robinson, Gruman, Gaztambide, & Blank, 2002). Furthermore, the CES-D may also be used as a measure of treatment results, as it determines the current symptom level and is sensitive to changes over time (Radloff, 1977; Radloff & Teri, 1986). It is also noteworthy that the presence of cognitive impairment did not have a negative effect on the efficacy of the CES-D as a screening instrument in this sample. This finding is consistent with those in other studies. Parmelee, Katz, and Lawton (1991) and Parmelee, Lawton, and Katz (1989) found that, with the exception of the severe dementia group, on comparing participants with cognitive impairment with those without cognitive impairment, the self-reports on depression had the same internal consistency and had correlations equivalent to the examiners’ evaluations. These findings, as do ours, suggest that older persons are reliable informers of their affective state, regardless of whether they have of cognitive impairment or not. Lastly, in our study the proportion of women with depression is greater than that of men. Nevertheless, we think that this difference does not affect the validity of the results. O’Rourke (2004) found that CES-D responses do not vary depending on the subject’s sex. Moreover, different studies have shown that women have higher rates of depressive symptoms (Thoits, 1995; Vingerhoets & Van Heck, 1990) and suffer from higher rates of affect disorders (Haro, Palacin, Vilagut, Martinez, Bernal, Luque, et al., 2006; Nolen-Hoeksema, 2001) than men. Furthermore, the scales and screening instruments that evaluate depressive symptoms are usually applied to both men and women with the same cut-off points. This study has some limitations. One of them is that the sample of older persons with cognitive impairment used to assess the validity of the CES-D as a screening instrument, did not include persons with moderate or severe cognitive impairment. Therefore, although we can conclude that the CES-D provides an adequate measure of depressive symptoms in older adults with mild cognitive impairment, we cannot extend this conclusion to include adults with more severe cognitive impairment.


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Finally, the sample size of the group without cognitive impairment is small for the type of statistical analysis that is being performed, so these results should be interpreted with caution. Nevertheless, it should be noted that our results fit with most of the previous literature in that some investigators have recommended cut-off points between 20 and 27 in older populations. In summary, we can conclude that the CES-D is a valid, reliable self-report scale to measure depressive symptoms in an elderly population and an efficient instrument for MDD screening in an older adult population with or without mild cognitive impairment. As we have seen, the CES-D is widely used in geriatric research worldwide and when compared with clinical criteria it has internal consistency, test-retest reliability, and satisfactory convergent validity (Grayson, Mackinnon, Jorm, Creasey, & Broe, 2000). We consider that validating its use in samples of older Spanish adults with or without mild cognitive impairment extends our knowledge of psychometrics, enables comparisons between different population types in different countries, and provides for the performance of inter-cultural studies. In our opinion, future studies should be directed toward examining how, for example, more severe cognitive impairment, functional disability, or physical illness in older adults could affect the adequacy of the CES-D as a measure of depressive symptoms. Furthermore, it would also be useful to compare the efficacy of different instruments used as screening tools for depressive disorders in this type of population, such as the GDS (Brink, Yesavage, & Lum, 1982). Finally, another interesting area of research is the evaluation of the adequacy of the CES-D to the immigrant population. Some studies have been shown that the immigrant experience has various psychosocial effects on older people, with possible implications for both cognitive functioning and mental health (Bhugra, 2004; Kulla, Ekman, & Sarvimäki, 2010). Thus, for example, it would be useful to test if the cut-off points obtained in this study are valid for screening depression in Spanish-speaking immigrants with and without cognitive impairment. (Appendix follows)

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APPENDIX Escala CES-D Para cada uno de los siguientes enunciados, elija la casilla que mejor describa CÓMO SE SENTÍA LA SEMANA PASADA: NINGUNA POCAS BASTANTES MUCHAS VEZ VECES VECES VECES 1. Me molestaron cosas que normalmente no me molestan 2. Me tenía hambre, no me apetecía comer 3. Me sentía triste y descorazonado, a pesar de la ayuda de mi familia y mis amigos 4. Me sentía tan válido y útil como cualquiera 5. Tenía dificultad para concentrarme 6. Me sentía deprimido 7. Para hacer cualquier cosa, tenía que hacer un gran esfuerzo 8. Me sentía con esperanza respecto al futuro 9. Pensaba que mi vida había sido un fracaso 10. Me sentía atemorizado 11. No me sentía descansado después de haber dormido 12. Me sentía feliz 13. Hablaba menos de los habitual 14. Me sentía solo 15. La gente no era amable 16. Disfrutaba de la vida 17. Hubo ratos en que lloré 18. Me sentía triste 19. Sentía que no le agradaba a la gente 20. Me encontraba sin fuerzas para hacer nada


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Direct reprint requests to: Laura Ros Department of Psychology University of Castilla La Mancha Avda. Almansa 14 02006 Albacete Spain e-mail: [email protected]